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Objectives: This study sought to evaluate the effects of veno-venous ultrafiltration on myocardial contractility in children undergoing cardiopulmonary bypass (CPB) for repair of congenital heart defects., Background: Ultrafiltration (UF) is currently used to diminish postoperative fluid accumulation following CPB in children. Previous reports indicate improvement in hemodynamics immediately after UF, but the mechanism of its action is unknown., Methods: Twenty-three patients (ages 2 months to 9.1 years; 13 males, 10 females) underwent UF for 10 min after CPB. Twelve patients underwent UF immediately after CPB (Group A). They were studied: (1) before and (2) after CPB, (3) after UF, and (4) 10 min after UF. Eleven patients underwent UF 10 min after CPB (Group B). They were studied: (1) before and (2) after CPB, (3) after a 10-min delay before UF, and (4) after UF. Contractility was determined by the difference in the observed and predicted velocity of circumferential fiber shortening for the measured wall stress, using transesophageal echocardiography. Left ventricular wall thickness was also measured., Results: There was significant improvement in contractility after UF in both groups (mean+/-SD, Group A: -0.28+/-0.13 to -0.01+/-0.21 circ/s, p < 0.05; Group B: -0.26+/-0.16 to -0.11+/-0.17 circ/s, p < 0.05). Myocardial thickness to cavity dimension decreased in both groups following UF (Group A: 0.19+/-0.04 to 0.14+/-0.03, p < 0.05; Group B: 0.18+/-0.04 to 0.14+/-0.03, p < 0.05)., Conclusions: UF improves hemodynamics by improving contractility and possibly by reducing myocardial edema in children following cardiac surgery. Enhanced patient outcome after ultrafiltration may in part be due to these changes.

A rare window type of patent ductus arteriosus is reported that was large (15 mm in maximal transverse dimension) but had virtually no length and hence was externally invisible. The smaller aortic isthmus (4 mm in diameter), which was intrapericardial, was mistaken for the ductus and was inadvertently clip-occluded, leading to death. After a specific diagnosis is made, the large window ductus should be patched on cardiopulmonary bypass with a transpulmonary approach.

Abnormal enlargement or malposition of any vascular structure or mass adjacent to the airway can cause extrinsic airway compression. In children with previous surgery for congenital heart disease, mass effect from prosthetic devices or alteration in the anatomic position of normal structures can lead to extrinsic airway compression. Because many children have complex medical problems after cardiac surgery, wheezing may be attributed to cardiac causes and airway compression may not be investigated. Furthermore, the distal airway compression seen in these children often is not visualized on chest radiographs. MR imaging can be useful in evaluating extrinsic airway compression in these patients. We present the MR imaging of two patients with symptomatic extrinsic airway compression secondary to pulmonary arterial conduits.

Objective: To better appreciate the complex nature of the pediatric patient with tracheal stenosis due to congenital complete tracheal rings, we evaluated clinical presentation, methods of evaluation, necessity for surgical repair, associated anomalies, and outcome., Design: Retrospective study., Patients: Eighteen patients with long-segment tracheal stenosis due to congenital complete tracheal rings were evaluated at Cincinnati (Ohio) Children's Hospital Medical Center between 1985 and 1991. Three patients did not require surgical intervention. Fifteen patients underwent tracheoplasty with cardiopulmonary bypass through a midline sternotomy., Results: The patients with congenital complete tracheal rings usually present with respiratory compromise in the first year of life. In the majority of patients, a diagnosis was made based on the symptoms and findings of an endoscopic examination with the aid of plain film roentgenography. In selected patients, computed tomography or magnetic resonance imaging was used. We evaluated symptoms, length of stenosis, type of repair, duration of intubation, and complications, as well as the mortality associated with this procedure., Conclusions: The technique of tracheoplasty has evolved at our institution, including the use of a posterior tracheal division, anterior castellated division, autologous pericardial patch grafting, and cricoid split with intubation for 7 to 21 days. We found the mortality associated with this procedure quite high at 47%, compared with previously published reports with mortality figures between zero and 77%.

From 1985 to 1990, 89 patients underwent placement of 41 aortic and 54 pulmonic cryopreserved allograft valved conduits between the right ventricle and the pulmonary arteries. Six patients underwent replacement with a second allograft conduit. Median age at operation was 4.3 years, and 20 patients were infants less than 1 year of age. Conduit sizes averaged 11 mm in the conduits placed in 20 infants and 20 mm in the 75 placed in patients more than 1 year of age. There were 7 early deaths in 89 patients (7.8%, 70% confidence levels 5.4% to 11.3%) and 9 late deaths in 82 hospital survivors (11%, 70% confidence levels 8% to 15%). Actuarial survival was 81% (70% confidence levels 75% to 86%) at 33 months, and no deaths were due to conduit problems. Late reoperation was required in 13 patients (7 for conduit obstruction, 1 for conduit valve insufficiency, and 5 for nonconduit-related problems). Six of the eight reoperations were done in patients who had small (< or = 13 mm) conduits placed during infancy. Conduit failure was similar between pulmonic and aortic allografts. There were no deaths in the eight patients who required conduit reoperation. Actuarial freedom from reoperation for conduit dysfunction was 80.5% (70% confidence levels 72% to 86%) at 53 months for the entire group and 94% (confidence levels 88% to 97%) at 44 months for patients more than 1 year of age. Cryopreserved allograft conduits have good early and midterm results and are comparable to porcine xenograft conduits. Despite a likely need for replacement within 3 years, we continue to favor the use in infants of an allograft valved conduit over a xenograft Dacron conduit. The need to replace a cryopreserved allograft conduit appears similar for conduits of aortic or pulmonic origin.

The standard treatment of innominate artery compression of the trachea has been innominate artery suspension, but the syndrome can recur when this technique is used. From October 1985 until March 1991, 29 infants and children were treated for this syndrome by innominate artery reimplantation. In all patients severe anterior vascular compression of the trachea was demonstrated preoperatively by bronchoscopy and in 17 the diagnosis was confirmed by magnetic resonance imaging scanning. Indications for operation included apneic episodes in 17 (58.6%), severe stridor in seven (24.1%), recurrent bronchopulmonary infections in four (13.8%), and exercise-induced stridor in one (3.4%). Through a median sternotomy, the innominate artery was reimplanted more proximally on the ascending aorta and to the right of the trachea. In this new position, the innominate artery no longer crosses the trachea anteriorly, and the anatomic cause of tracheal obstruction is completely eliminated. There were no early or late deaths, and 27 of the 29 patients (93%) had complete resolution of symptoms. Partial resolution of symptoms was seen in two patients (7%). Reimplantation of the innominate artery offers a unique method by which the anatomic cause of tracheal compression is eliminated. It is a safe and effective means of treating symptomatic compression of the trachea by the innominate artery.

The treatment of patients with primary spontaneous pneumothorax remains controversial, since recurrence and the ultimate need for thoracotomy [corrected] cannot be predicted. In the current study, computed tomography (CT) of the lung was performed prospectively on 26 consecutive patients with primary spontaneous pneumothorax to determine whether the size and/or the number of apical blebs would correlate with recurrence and/or need for thoracotomy [corrected]. Both the number of blebs and the bleb score (calculated by the number of blebs multiplied by a numeric value assigned a range of bleb sizes) of the affected lung was significantly greater in patients with a history of recurrent pneumothorax and/or ultimate need for thoracotomy [corrected] as treatment. CT of the lung may be useful in predicting the natural history of pneumothorax.

Pulmonary dysfunction after cardiopulmonary bypass has been attributed to the damaging effects of complement activation on the lung. To further explore this phenomenon, we measured plasma levels of activated complement components (radioimmunoassay), assessed neutrophil n-formyl-methionyl-leucyl-phenylalanine (FMLP) receptor status (radioligand saturation binding assay), and quantified pulmonary epithelial permeability as radioaerosol lung clearance of technetium 99m-labeled diethylenetriamine pentaacetic acid in a series of 8 patients undergoing cardiopulmonary bypass. Significant elevations of plasma C3adesArg, C4adesArg, and C5adesArg levels were seen just after CPB, indicating activation of both the classic and alternate complement pathways. Neutrophil activation was evident as increased expression of neutrophil FMLP surface receptors after bypass. Despite the presence of complement and neutrophil activation, increased pulmonary epithelial permeability was not seen. These data support the hypothesis that complement and neutrophil activation during cardiopulmonary bypass is not associated with acute lung injury, at least not pulmonary epithelial injury. One can therefore infer that increased pulmonary epithelial permeability in patients at high risk for and experiencing sepsis-induced and trauma-induced adult respiratory distress syndrome may be due to factors other than complement and neutrophil activation.

The purpose of this study was to assess the utility of MR imaging in identifying anatomic features of vascular rings. MR imaging of the thorax was performed in five consecutive children with symptoms and findings of vascular rings on barium esophagography. The diagnoses were subsequently proved at surgery and/or angiography. Preoperative definition of the anatomy was adequate and accurate in each case. Our preliminary experience with MR imaging in five patients with vascular rings suggests that this technique is an excellent alternative to angiography when further anatomic delineation of the abnormality is required.

Doppler echocardiography has been shown to have high sensitivity and specificity for noninvasive detection of the flow disturbance of ventricular septal defect. After surgery for ventricular septal defect, one might expect loss of the ventricular septal defect flow disturbance. We used two-dimensional and pulsed Doppler echocardiography to evaluate 30 children undergoing surgery for ventricular septal defect to determine postoperative Doppler findings and the effect of ventricular septal defect patch material on those findings. Twenty-one patients had Dacron patches and nine pericardial patches. Doppler examinations were performed immediately after surgery and at intervals thereafter. The patches were imaged on two-dimensional echocardiograms and the Doppler method was used to evaluate flow at the patches. Doppler echocardiography was also used to estimate volume flow in the aorta and pulmonary artery to estimate postoperative ratio of pulmonary to systemic flow (Qp/Qs). Immediately after surgery 93% of patients had a flow disturbance detected by Doppler echocardiography in the region of the surgically placed patch. On postoperative day 1, 62% of Dacron-patched defects and 66% of pericardial patched defects showed evidence of residual shunting on Doppler examination. By the third postoperative day, this prevalence fell to 23% and 44%, respectively. By 2 weeks after surgery there was evidence of residual shunting in only two patients. In 26 of 30 early postoperative Qp/Qs estimates were under 1.6/1; all but two of these lost the Doppler-detected flow disturbance by 2 weeks after surgery. In three of 30 Qp/Qs estimates exceeded 1.9/1; two of these three required reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)

Six patients with large mycotic aortic annular aneurysms were successfully operated on over a 3-year period. Aortic valve replacement was facilitated in all six patients by closing the orifice of the abscess with a Dacron patch and then seating the prosthetic valve at the level of the aortic annulus. In each case, a portion of the prosthetic valve ring was sutured directly to the patch. No patient has clinical evidence of a perivalvular leak 18-48 months after operation. One patient required reoperation to close a ventricular septal defect caused by partial patch dehiscence. Dacron patch closure has been highly effective in our experience and is simpler than many other options.

Radionuclide equilibrium gated ventriculograms were performed in 23 infants before and after surgery for congenital heart disease using standard parallel hole general purpose collimation followed by a pinhole collimation technique to magnify images and improve spatial resolution. A second group of nine infants had pinhole collimated gated ventriculography during cardiac catheterization for comparison with cineangiographic ejection fraction. In group I, pinhole collimation gave improved ventricular and atrial separation over general purpose parallel collimation for determination of left ventricular ejection fraction (42 of 42 studies calculable vs 37 of 42) and for right ventricular ejection fraction (36 of 37 studies calculable vs 20 of 37). In patients with transposition, pinhole technique allowed right ventricular ejection determination in nine of nine studies but in only one of nine was right ventricular ejection fraction possible by standard parallel collimation. In group II, the correlation between left ventricular ejection fraction by cineangiography and pinhole radionuclide ventriculography was excellent (r = 0.95). The correlation for right ventricular ejection fraction between cineangiography and pinhole radionuclide ventriculography was 0.82. Pinhole radionuclide ventriculography is a useful, practical clinical tool that can be used to assess ventricular function in small infants in an intensive care or outpatient setting.

The feasibility and potential adverse effects of using intraoperative transesophageal echocardiography (TEE) in 19 children ages 7.5 to 16 years undergoing surgical repair of a variety of congenital heart defects were evaluated. The ability of TEE to assess the adequacy of surgical repair as well as left ventricular function and wall motion abnormalities in this setting was also examined. Intraoperative transesophageal 2-dimensional and Doppler evaluation, and, in selected patients, echo-contrast and color flow imaging, were performed with either a 3.5- or 5.0-MHz phased array probe mounted within the tip of a flexible gastroscope. Probe insertion was successful in 18 of 19 patients. Fiberoptic endoscopy (9 patients) and autopsy (1 patient--cardiac donor) performed within 24 hours of surgery demonstrated no significant esophageal abnormalities. Intraoperative wall motion abnormalities were identified in 8 patients but did not persist after the operation. An adequate surgical repair was demonstrated by contrast and color flow imaging in most patients. Microcavitation was detected in 6 patients for greater than 5 minutes after a standard debubbling procedure. No patient displayed any adverse neurologic effects. It is concluded that, with the currently available probes, intraoperative TEE can be performed safely and reliably in children as young as 7.5 years of age. The procedure provides valuable information regarding wall motion abnormalities, cardiac function and the adequacy of surgical repair.

The occurrence of stroke associated with coronary artery bypass operations is approximately 2%. In an attempt to reduce this incidence some centers have proposed carotid thromboendarterectomy for symptomatic and asymptomatic carotid arterial disease in patients undergoing a coronary artery bypass operation. To obtain a better understanding of the incidence of carotid occlusive disease in candidates for the coronary bypass operation and to evaluate the practical use of a noninvasive method to screen patients preoperatively, we evaluated 102 patients preoperatively with an ultrasonic Duplex scanner; 24 studies were requested on the basis of either previous neurologic problems or the presence of a bruit and 78 patients were evaluated as part of a study protocol. In the unrequested group 6% (5/78) of the patients had a stenosis of 50% diameter reduction or more. In the requested group 54% (13/24) had a stenosis of 50% diameter reduction or more. In the postoperative phase one stroke and one transient ischemic attack were noted among the unrequested group and none in those suspected of having carotid disease on clinical grounds. Neither affected patient had a high-grade stenosis. There is little evidence to support the contention that noninvasive screening of patients free of symptoms or signs of carotid disease prior to coronary artery bypass operation is a valuable method of screening for patients who will sustain a focal neurologic event.

One common vascular anomaly that causes airway obstruction in neonates and infants is innominate artery compression of the trachea. A great deal of controversy exists regarding the effect of this anatomic variant on symptom production. Several cases are presented that demonstrate the unique features of innominate artery compression of the trachea: 1. Innominate artery compression can occur in adolescent patients. 2. Flow volume loops are an effective method of documenting airway compromise in this condition. 3. Exercise intolerance should be considered as a relative indication for surgical intervention in these patients. 4. Reimplantation of the innominate artery is a viable surgical alternative in the treatment of affected patients. 5. Telescopic bronchoscopy during surgical correction of this condition will ensure that there has been successful correction of the tracheal compression. 6. Urgent repair is advocated in patients who experience periods of apnea.

By means of postoperative radionuclide angiography we identified a subset of infants undergoing primary repair of their ventricular septal defects (VSD) who had postoperative morbidity and ventricular dysfunction. Twenty-three consecutive infants undergoing repair of an uncomplicated VSD were studied. Radionuclide-determined postoperative ventricular dysfunction (VD), as defined by a left ventricular ejection fraction less than 0.30 2 to 4 hours after surgery, was correlated with clinical signs of postoperative morbidity. Six patients developed postoperative VD. Clinical correlates of VD included the use of postoperative inotropic support, increased number of postoperative intensive care days, and a low growth rate 3 months postoperatively. Potential predictors of VD were evaluated. A preoperative pulmonary-to-systemic blood flow ratio (Qp/Qs) greater than 3.0 and a pulmonary-to-systemic vascular resistance ratio (Rp/Rs) less than 0.20, taken in combination, gave a positive predictive value for VD of 100%. It is concluded that the preoperative Qp/Qs and Rp/Rs can be used to predict those infants at risk for postoperative morbidity following repair of their VSD.

Eighty-five patients operated on before January 1976 have survived at least 30 days after insertion of a valved external conduit by the venous ventricle (usually the right) and the pulmonary arteries as a part of the repair of their congenital heart disease. Follow-up information is available on 83 patients, and mean follow-up time has been 27.7 months. Seven patients have required reoperation because of obstructive complications. Actuarial analysis indicates that the proportion of patients requiring reoperation is 4.0 +/- 2.8% at 2 years, 12.9 +/- 5.5% at 3 1/2 years, and 30.4 +/- 12.1% at 5 years. In five patients compression of the conduit between the sternum and heart was the primary cause of the obstruction. The proportion requiring reoperation for conduit compression is 2.0 +/- 2.0% at 2 years, 8.6 +/- 4.9% at 3 1/2 years, and 27 +/- 12.4% at 5 years. Age at operation is not related to the proportion of patients requiring reoperation, nor is the type of conduit. No patients have yet required reoperation for conduit compression whose operation has been done since we began systematically to position the conduit well away from the sternum. By actuarial analysis the proportion of patients surviving 5 years is 76.7%. Of those alive at follow-up examination, 78% were without limitation of activity.

A modified technique for trimming and inserting the aortic homograft valve is described. This altered free-hand technique is designed to maintain normal spacial geometry of the valve apparatus in order to reduce the risk of early homograft valve incompetence.

A total of 116 patients undergoing coronary revascularization were randomized preoperatively in a double-blind manner to receive 80 mg daily of propranolol or placebo in the postoperative period. Preoperatively, all patients had been receiving at least 80 mg of propranolol a day to the time of the operation. In addition, all patients had a left ventricular ejection fraction of 0.4 or more, no history of supraventricular tachyarrhythmia (SVT), and no need of digitalis preparations or other antiarrhythmic drugs. All patients were monitored for 5 days and propranolol or placebo was started 24 hours postoperatively. SVT was documented with biatrial electrograms in all cases. Study groups were similar in postoperative creatine kinase MB levels and postoperative weight gain, but the placebo group tended to be older and have more grafts per patient. Seven patients randomized were dropped from the study, two with perioperative infarction, four with persistent ventricular arrhythmias necessitating quinidine or procainamide, and one with persistent postoperative hypotension (placebo). There were no significant differences in the incidence of postoperative SVT in these two groups: 13.2% in the propranolol group and 16.1% in the placebo group. We conclude that 80 mg daily of propranolol given postoperatively to patients undergoing coronary revascularization does not effectively reduce the incidence of SVT.

Pulsed Doppler echocardiography has been used to detect continuous turbulent flow in the right pulmonary artery after Blalock-Taussig shunts. Since continuous turbulent flow could also arise from patent ductus arteriosus (frequently present in the neonate), continuous turbulent flow in the right pulmonary artery is not specific for Blalock-Taussig shunt function. We evaluated 35 Blalock-Taussig shunts from suprasternal or high parasternal approach for flow in the right pulmonary artery, and in the Blalock-Taussig shunts themselves. From precordial approach, Doppler evaluations of the main pulmonary artery were also made in search of flow characteristic of patent ductus arteriosus. Doppler detection of flow within the Blalock-Taussig shunts indicated shunt patency, and indicated that continuous turbulent flow in the right pulmonary artery was not due to only patent ductus arteriosus. Shunts were proven patent in 31 patients, occluded in four. Twelve patients also had patent ductus arteriosus. By Doppler, the right pulmonary artery had continuous turbulent flow in 30 of 31 patients in whom the right pulmonary artery was found. From the suprasternal or high parasternal approach, the right Blalock-Taussig shunts were detected by marked continuous turbulent flow directed away from the transducer, between the aortic and superior vena caval flow signals. Left Blalock-Taussig shunts had similar directional continuous turbulent flow. Prosthetic shunts were identified by the dense shunt material. Twenty-four of 31 functional shunts were identified, and all contained continuous turbulent flow. Three left-sided shunts were missed. All four occluded shunts were identified by Doppler, and had no lumen flow within.(ABSTRACT TRUNCATED AT 250 WORDS)

We obtained information from 677 cardiac surgeons in the United States on the type of practice, case load, and techniques currently used for coronary bypass operations. These surgeons collectively performed 93,000 bypass operations in 1979. Less than 25% of these procedures were done in university or federal hospitals; the majority were performed in the private sector by surgeons engaged in a single specialty group practice. The mean case load in 1979 was 137 operations per surgeon, and only 46 (6.8%) did fewer than 25 bypass operations during that year. These surgeons devote a relatively small percentage of their professional activity to other areas in thoracic surgery--the majority do not perform congenital heart surgery and two thirds devote less than 10% of their professional activity to general thoracic surgery. Compared with our previous national survey done in 1975, techniques used for bypass grafting have changed considerably over the past 5 years. An increasing number of surgeons conduct cardiopulmonary bypass with an arterial input line introduced into the ascending aorta and with a single cannula for venous drainage and do not routinely vent the left ventricle. Cold chemical cardioplegia has become the technique of choice (by 91% of surgeons) for myocardial protection, sequential bypass grafts are now widely employed, and 83.2% of surgeons perform all distal anastomoses during a single period of cardioplegic arrest.

Cryopreserved homograft pulmonary valves were used as a valved external conduit between the right ventricle and native pulmonary arteries in 21 patients with complex congenital heart disease. The technique used to construct the conduit was modified after incompetence of the valve was detected early in 3 of the first 9 conduits. The next 12 conduits remained competent. This experience suggests that early valve competency can be achieved if the valve is not distorted during construction of the conduit.

To assess the efficacy of surgical revascularization for postinfarction angina within 30 days of acute infarction, the clinical course of 103 patients treated surgically from January 1979 to July 1982 was reviewed. There were 84 men (82%) and 19 women (18%) with a mean age of 58 years (range 34 to 80). Group A (11 patients) underwent surgery within 24 hours of infarction, Group B (21 patients) within 7 days and Group C (71 patients) within 30 days. Eighty-four patients (82%) had subendocardial infarctions and 19 patients (18%) had transmural infarction. Transmural infarction was more common in patients in Group A (36%) than in those in either Group B (19%) or Group C (15%). There were two deaths, both in Group C (1.9%), within 30 days of surgery. The use of intraaortic balloon or inotropic support and the occurrence of major arrhythmias or perioperative infarction was noted in 30 patients (29%) (64% in Group A, 33% in Group B and 18% in Group C). The average time in the intensive care unit was 3.2 days, with an average total hospital stay after surgery of 8.3 days. Late follow-up (mean 15.4 months, range 1 to 39) is complete for 97 patients (97%). There were no late myocardial infarctions and 93 patients (96%) were essentially free of angina. The only late death (1.0%) was caused by septicemia from delayed sternal wound infection. This study suggests that myocardial revascularization within the first 30 days after myocardial infarction can be accomplished with an acceptable operative mortality in selected patients with postinfarction angina refractory to medical management.

Complement-mediated neutrophil activation (CMNA) has been implicated as an important pathophysiologic mechanism contributing to acute microvascular lung injury in the adult respiratory distress syndrome (ARDS). Using cardiopulmonary bypass (CPB) as a clinical model for complement-mediated microvascular injury, we studied the effects of methylprednisolone (MPSS) pretreatment on manifestations of CMNA in 28 pediatric patients undergoing CPB. Six patients not receiving MPSS served as controls. Results demonstrated that MPSS did not prevent complement activation as noted by 4.5- and 7.7-fold increases in plasma C3a des Arg levels during and immediately after CPB, respectively. However, detectable in vivo and in vitro manifestations of CMNA were altered. Neutropenia during CPB was attenuated to 65% of prebypass values compared with 47% in the control group. Neutrophil selective chemotactic desensitization toward C5a/C5a des Arg during the on bypass and postbypass periods was evident in the control group (0.41 and 0.76 cm specific migration, respectively) and prevented in the MPSS group (1.55 and 2.00 cm specific migration, respectively). We conclude that CMNA during CPB is ameliorated and/or prevented by MPSS pretreatment. These findings suggest that MPSS pretreatment may ameliorate complement-mediated microvascular (lung) injury in CPB and ARDS.

From November, 1980, to May 1985, 699 patients have undergone percutaneous transluminal coronary angioplasty of 784 lesions at our institutions. Simultaneous surgical standby was available on all cases. One hundred twenty-four patients (18%) underwent immediate myocardial revascularization; 45 (6%) were operated on because the lesion could not be dilated. Seventy-nine patients (11%) underwent immediate operation for an acute complication of angioplasty: coronary occlusion in 45, dissection in 29, coronary perforation in three, and atrial perforation in one. Fourteen patients (18%) required cardiopulmonary resuscitation en route to the operating room, and 10 patients (20%) had insertion of an intra-aortic balloon pump in the cardiac catheterization laboratory. The average time from complication to reperfusion was 87 minutes, ranging from 40 to 165 minutes. An average of 2.0 grafts per patient (ranging from one to five grafts per patient) were performed. Of those 79 patients who underwent operation for an acute complication, one died (1.3%), 31 patients (39%) had a myocardial infarction according to enzyme criteria (creatine kinase-myocardial band greater than 40 IU), and 17 patients (22%) had new Q waves on the electrocardiogram. Good results are related to minimizing the time the myocardium is ischemic. No patient in whom reperfusion was begun in less than 75 minutes had a Q wave infarction or a creatine kinase-myocardial band level greater than 40 IU. Simultaneous surgical standby is the only method allowing immediate access to surgical facilities. A standby team of eight persons and equipment were immediately available for emergency bypass grafting for an average of 3.6 hours (range 1.3 to 5.4 hours per angioplasty attempt). The patient charges for this simultaneous standby were $632.00 per angioplasty attempt, or $442,278.00 for the entire series. The actual cost of the standby was over $1,700.00 per attempt totaling $1,188,843.00 for the 699 patients. This underestimation of the cost of surgical standby has occurred in other series, because little mention has been made of this cost in the published reports on the cost effectiveness of angioplasty. In terms of time demands, over 2,500 hours were spent by surgeons standing by for the 699 attempts. Simultaneous surgical standby is the most effective means of limiting the time the myocardium is ischemic after an angioplasty complication. However, this method is costly, necessitating more of a financial and time commitment than generally anticipated. Future studies of the cost effectiveness of angioplasty should include the cost of surgical standby with accurate per-patient cost accountability.

A 34-year-old man had a posttraumatic, pelvic arteriovenous fistula (AVF) and false aneurysm of 18 years' duration. He had undergone four previous unsuccessful attempts at operative repair, the last of which almost resulted in exsanguination. After the false aneurysm was exposed, the patient was placed on cardiopulmonary bypass. Core cooling (25 degrees C) allowed the perfusion flow rates to be lowered (less than 0.5 L/min/m2) while the aneurysm was opened, thereby permitting visualization and ligation of the arteriovenous communications within the aneurysm. Total circulatory arrest was not required. There were no complications and the patient was discharged on the eleventh postoperative day. Arteriography 5 months later showed complete ablation of the AVF. We believe that cardiopulmonary bypass with hypothermia and reduced blood flow is a useful adjunct in the repair of complex AVFs and arteriovenous malformations. This technique avoids the use of total circulatory arrest, which increases the risks of air embolism and ischemic organ injury.